· web viewapril 5: nyc health commissioner and hospital commission announce to public threat...
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PUBLIC HEALTH IN ACTION: PAST & PRESENTNew York City, 1947Index Case
Man on way from Mexico to Maine Falls ill in NYC, March 1
o Goes to Bellevue for fever, rash o Admitted to dermatology ward o Transferred to Willard Parker ID hospital
with unknown diagnosis o Mar 10: dies, dx: bronchitis with
hemorrhage o 2 more cases develop �
Smallpox suspected Willard Parker staff vaccinated
Keep in Mind Smallpox hadn’t been seen in over a generation In NYC, ~2 million out of 7.5 million had any
immunityFurther Developments
April 4: Lab reports smallpox April 5: NYC Health Commissioner and Hospital
Commission announce to publico Threat slighto Vaccination importanto Alternative Care Sites –places are
nontraditional patients that you deliver care Two-Pronged Attack
Mass Vaccination Campaign Case-tracing US PHS wades in also
To Win Public Confidence Daily press conferences
o Announcements of suspected/confirmed cases
Coordination among city, state, & Federal agencies Smallpox signs distributed Lapel buttons
o “Be safe. Be sure. Get vaccinated” Radio shows about Smallpox
Enough Vaccine? Drug companies hesitant about supplies and cost of
vaccine. Mayor O’Dwyer had them in City Hall
o Ultimatum: Make more vaccine, make it cheaply, or won’t leave building!
Vaccination Campaign Free, voluntary
o Health Dept. had authority to remove people forcibly and to demand vaccination
o Authority not used; coercion not needed o Assistance of local volunteer groups
Hospitals, doctors’ offices, health department clinics 13 hospitals, 84 police precincts, public and private
schoolsPublic Confidence & Trust High
—First 2 weeks: 5 million vaccinated — In 2 weeks: 6.35 million vaccinated
o Mayor vaccinated
o President Truman vaccinatedo Final results
Expected <5,000 cases Actual: 12 cases, 2 dead
Why Successful? American mentality Post-war Emergency mentality still in force Trust in government continues Strong Public Health infrastructure Public treated as associates in common problem
AN UNUSUAL CASE OF TERRORISM 2002-200312/31/02-1/01/03
Four families (18 members) complain to one supermarket in Michigan of becoming ill following the consumption of ground beef they bought there.
Symptoms includeo Burning of the mouth o Nausea, vomiting.o Dizzinesso One case of atrial fibrillation treated at a
local ED1/03/03
The supermarket notifies the Michigan Department of Agriculture (MDA) Food and Dairy Division and the US Department of Agriculture (USDA)
Recall 1,700 lbs. of ground beef because of customer complaints.
1/08/03 The supermarket issues a press release about the
recall of all ground beef with a “sell-by” date between 1/01/03 and 1/03/03.
After the initial recall, 36 other customers report illness associated with the ground beef.
120 customers return the tainted product. 1/10/03
The supermarket notifies MDA that their own independent lab determined that the beef was contaminated with nicotine (300mg/kg in submitted beef samples).
The USDA and the FBI become involved in the investigation
1/17/03 The supermarket issues a press release that the
ground beef in question contains unspecified non-bacterial contaminants that are unable to be rendered harmless by cooking.
The contamination appears to be localized at the one supermarket since other supermarkets receiving the beef from one meat processing plant report no problems.
1/23/03 The local health department alert local EDs and
selected medical practices about the situation.1/24/03
The supermarket issues a press release that the contaminant was nicotine.
Health Department Activities Develops a case definition Conducts epidemiological investigation
o 148 interviews 92 persons had illness consistent
with the case definition Median age: 31 yrs. (range: 1-76
yrs.) 50% female Cases occurred immediately after
sale and as late as 49 days after sale suggesting that the beef was frozen for later consumption
3% sought medical attention2/12/03
Grand jury indicts one disgruntled supermarket employee with the intentional poisoning of 200 lbs. of ground beef with nicotine.
Source of the nicotine was from an insecticide called Black Leaf 40 (40% nicotine).
BATS ON A PLANEAugust 5, 2011
At 6:45 a.m.: A commercial airliner carrying 50 souls from Wisconsin to Georgia.
Shortly after takeoff, a bat flew from the rear of the aircraft through the cabin several times before being trapped in the lavatory.
The aircraft returned to the airport. All passengers disembarked to allow maintenance
crew members to remove the bat from the aircraft. The bat escapes.
WI Department of Public Health On August 8, WDPH was notified of a news report
describing the incident WDPH requested assistance from CDC to conduct a
multistate investigation, assessing the potential risk for rabies and the need for rabies post-exposure prophylaxis among passengers, the flight crew, and ground crew members associated with the flight.
Epi Team in Action In all, CDC interviewed 45 (90%) of the 50 passengers
on board the initial flight and confirmed that none had physical contact with the bat or exposure to its saliva, and all were alert during the flight.
The 45 passengers were residents of 11 states. They ranged in age from 2 to 63 years (mean: 41.2 years), and 24 (53%) were male. Two passengers reported having been vaccinated previously against rabies.
The airline conducted the risk assessment of the two pilots, one flight attendant, and 16 ground crew members associated with the flight.
o None of the airline personnel reported contact with the bat, bat saliva, or altered alertness during the incident.
Decision
Post-exposure prophylaxis not indicated
DELIRIUM OF UNKNOWN ETIOLOGYThe Presentation
In late December 2010 A male resident of Wisconsin, aged 70 years, sought
treatment for progressive right shoulder pain, tremors, abnormal behavior, and dysphagia at an ED.
Progression Admitted for observation Treated with benzodiazepines and haloperidol for
presumed alcohol withdrawal syndrome. Next day: Rhabdomyolysis, fever, and rigidity
o Neuroleptic malignant syndrome was diagnosed.
The patient worsenedo Encephalopathy, respiratory failure, acute
renal failure requiring hemodialysis, and episodes of cardiac arrest.
The Diagnosis The patient died on hospital day 13.
Once diagnosis made.... Hospitals and DPH staff members initiated contact
investigation interviews with the patient’s family, friends, and health-care providers to determine the extent of exposure and need for post-exposure prophylaxis
176 health-care workers + patient’s family assessed
A MIGRANT FARM WORKER WITH FATIGUE AND SHOULDER PAINChief Complaint
On July 29, 2010, a previously healthy male, aged 19 years, from Michoacán, Mexico, arrived at a sugarcane plantation in Louisiana.
After 1 day of work in the fields, the patient sought medical attention on July 30 for generalized fatigue, left shoulder pain, and left hand numbness attributed to overexertion.
Physical Examination Hyperesthesia of the left shoulder, weakness of the
left hand, generalized areflexia, and drooping of the left upper eyelid.
LP: a mildly elevated white blood cell count of 8 cells/ mm3 with 67% lymphocytes and 12% neutrophils, a normal glucose, and no organisms on staining.
Initial Dx:o Miller-Fisher variant of Guillain-Barré
syndromeo Viral encephalitiso Early bacterial meningitis
When the results returned normal... Bacterial, viral, and fungal cultures of blood and CSF:
Negative.
Lab tests for HIV, syphilis, herpes simplex virus, arboviruses, Lyme disease, and autoimmune neuropathies: Negative.
No history of animal exposures was known at that time
A diagnosis of ? was suspected based on the clinical history and available data.
The Louisiana Office of Public Health was informed of the potential case of ?
Infection control precautions were instituted on August 13, the 11th hospital day.
Interventions Public health authorities in Louisiana and Mexico
interviewed the patient’s family members, friends, and coworkers to identify potential exposures.
In total, 95 of 204 (46.5%) patient contacts received prophylaxis. Of these, 27 were coworkers who reported sharing a drinking vessel with the patient, and 68 were health-care workers with various exposures.
A NURSING HOME UNDER FIREPromenade Rehabilitation and Health Care Center
140 Beach 114th Street Under fire Rockaway Park, Queens Allegedly, failed to provide the most basic care to its
patients, according to interviews with five employees, federal, city and hospital officials, and shelter directors.
As Sandy approached The State Health Department ordered all nursing
homes (this is a law) o to stay at 150 percent of normal staff levelso to stock three days’ worth of food and
medicineo to make sure to have a working generator
in case power failed.October 29
Hurricane Sandy blew out Promenade’s windows and sending waves washing through the first floor.
Generator on first floor disabled Back-up didn’t kick in.
o Note: A nursing home sits on either side of Promenade. Each had a generator placed off the ground or walled-off from the water. Promenade’s generator, by contrast, sat closer to ground level.
Hungry, cold, and in the dark Patients remained inside in the dark, growing
steadily more hungry and cold The kitchen had flooded, and the owners had not
stocked enough food, staff members say. One nurse: “It was scary; we were all petrified....We
tried not to show that to the patients.” Some workers failed to show up for assigned shifts.
Good Samaritans Next day
Staff at Park Nursing Home took pity and slapped together 150 sandwiches for the staff members and patients of Promenade.
To the rescue? Dr. Shah, NYS Health Commissioner, asked for help
from the hospitals of North Shore-LIJ Health System, which sent two safety officers out to the Rockaways at first light that Tuesday.
Every street the officers tried was blocked by floodwaters or fire trucks fighting a blaze several hundred feet from the nursing home.
Finally, that evening Ambulances arrived EMS struggled to carry wheelchairs and patients with
severe dementia down the stairs to waiting ambulances.o But some records and medications did not
follow. Nearly 200 patients evacuated over several hours Deposited in emergency shelters in the city.
o About 100 placed in four dimly lighted classrooms at Brooklyn Technical High School in Fort Greene, Brooklyn.
o Finger-stick and other blood tests Possible Violations
In most cases, allegedly, no Promenade staff member accompanied the patients
Many patients traveled without their medical records.
Both are violations of state regulations.As of November 9...
Some family members were still desperately searching for their loved ones
No help from Promenade staff These patients were found in various emergency
shelters or landed in cots and beds in hospitals and nursing homes across the region.
NY Times interviews with employees Promenade, allegedly, failed to carry out basic
responsibilities– Adding staff for the storm as required by
the state,– Stocking enough medicine and flashlights– Preparing patients’ records in case of
evacuation. During Hurricane Irene, Promenade allegedly sent its
patients off without staff members and often without medical records.
– The State Health Department did not investigate or fine Promenade in that case.
Curiouser and curiouser... The nursing home administrator, who runs the home
day to day, left the city — on what he said was a “personal matter” — on Oct. 28, as the hurricane approached.
The nursing director left the next afternoon to check on her sick husband;
o She did not return until Oct. 30, after the storm had blown over.
Dr. Nirav R. Shah, NYS health commissioner “My only priority is patient safety and health, and
everything you’ve asked about Promenade flies in the face of that.”
“We are investigating aggressively.”How much of the fault was NYS?
A year ago, when a less-powerful Tropical Storm Irene loomed, Dr. Shah ordered many nursing homes in the Rockaways to evacuate.
But he declined to do so last week in the face of Hurricane Sandy, even though the nursing homes lay in an evacuation zone.
What would you do? Dr. Shah said he gave the homes the option of not
evacuating, based on the risks of moving the elderly and the frail.
Nursing homes complained bitterly about the cost of evacuations last year during Irene.
Monday quarterbacking? Promenade’s owners....
Blamed the storm and state officials for the nursing home’s problems.
The nursing home had increased its staffing for the storm to 150 percent and had enough medicine, flashlights and food.
“What was crazy is the New York State Department of Health told us not to evacuate before the storm, so we sheltered in place,” one owner said. “I had to call them about 100 times before I was able to get the Office of Emergency Management to get them out.”
The patients all got out safely; no related deaths.He said, she said....
Dr. Shah and four Promenade workers dispute nearly every one of owner’s assertions
Shah: “I was talking to managers in just about every facility except Promenade. Not only did we not hear from them; we actively tried to contact Promenade and heard nothing.”
No Database The State Health Department has not yet completed
a database that would help family members find loved ones.
Louisiana put in place such a system in 2008 after Hurricane Gustav.
Physicians at the Vanguard
AN UNUSUAL HAPPENING IN THE BIG APPLE Case 1.
Mr. and Mrs. New Mexico travel to NYC November 5, 2002 The man (53 years) seeks medical care in a NYC ED
after consulting with his physician in New Mexico and the physician at the hotel at which he was staying.
In the ER 2 days of fever, fatigue, and painful unilateral
inguinal swelling. P/E: Appears ill with diaphoresis, rigors, and lower
extremity cyanosis. T: 104.4o F (40.2o C), B/P: 78/50 mm Hg, SaO2: 98%
(21%) P/E: Tender left inguinal adenopathy with overlying
edema. WBC: 24,700/μL , platelet count: 72,000/μL A blood culture grew ????. –yersinia pestis Gram stain of the blood culture isolate revealed
bipolar gram- negative rods with a "safety pin" appearance.
The patient's condition deteriorates Admitted to ICU in shock with a diagnosis of
septicemic ??????, acute renal failure, acute respiratory distress syndrome, and disseminated intravascular coagulation.
Required hemodialysis and mechanical ventilation Bilateral foot amputations After a 6-week ICU stay, he recovered and was
discharged to a long-term-care rehabilitation facility. Case 2: The Wife
November 3, the wife, aged 47 years, of patient 1 also became ill.
November 5, she sought medical care for fever, fatigue, myalgias, and unilateral inguinal swelling.
P/E: Tender right inguinal and femoral adenopathy T:102.2o F (39.0o C), B/P: 120/72 mm Hg, SaO2: 98%
(21%). WBC: 9,500/μL, platelet count: 189,000/μL. Hospitalized and treated with gentamicin,
doxycycline, and ticarcillin-clavulanic acid, followed by a 14-day course of oral doxycycline 100 mg twice daily
She recovered without complication.NYC Response
The hotel physician notified the ED about the patients and the need for respiratory isolation pending the exclusion of pulmonary infection.
Hospital infection-control and administration personnel were contacted to coordinate appropriate in-hospital precautions and education.
The NYC Department of Health and Mental Hygiene, the NYSDOH, NMDOH, and CDC were contacted to facilitate diagnostic testing, coordinate public health response, and assess the possibility of terrorism.
Reassurance After determining that these two cases probably
were acquired naturally, a press conference was held to reassure the public that the exposures had occurred in New Mexico, a known endemic area, and not in NYC.
DISCOVERING AN EPIDEMIC IN THE U.S.It all started in NYC, 1999A phone call
August 23, 1999 (Monday) Deborah Asnis
o Physician at Flushing Hospital Medical Center (Queens) �
Calls Marci Laytono Chief Epidemiologist, NYC DOH
Reason: Two Puzzles 60 year-old male & 75 year-old male Dr. Asnis’ patients Both
o Lost use of arms and legs �o High fevers �o CSF leukocytosis �o Confused
A plan Blood and CSF specimens to be sent to state lab in
AlbanyAnother phone call
Friday, August 27, 1999 Dr. Asnis reports on two more patients
o 80 year-old maleo 87 year-old female
Another neurologist overhears conversationo Has another similar encephalitic patient in
another hospitalNYC DOH Makes a Visit
o Saturday, Layton & Annie Fine visit Flushing Hospital to review cases
o Three now on mechanical ventilators o Commonality: All lived within same two-square-
mile area of northern Queens Simultaneous Admission at Flushing Hospital
57 year-old maleo Fever, combative, hallucinatoryo Came from same neighborhood as others
At End of Weekend Eight additional patients with similar manifestations
identified in hospitals in Queens.
CDC Sunday:
o Layton calls CDC for assistance Tuesday:
o EIS (Epidemic Intelligence Service, CDC) Officer Kristy Murray arrives
o More cases appear Wednesday:
o Murray visits hospitals Reviews patient charts Interviews patients
o Denis Nash (EIS at NYC AIDS unit) Visits patients’ homes with exterminator,
animal-disease expert, entomologistClue
At one patient’s home, Nash’s team discoverso Mosquito Paradise: Standing water (birdbath),
thick grass Patient and other patients were avid gardeners
Patient taken off life supportAnother death
Thursday 87 year-old lady dies
Lab Results Friday NY & CDC tests
o Positive for St. Louis Encephalitis (SLE) viral antibodies in blood and CSF specimens
Mayor Giuliani Press conference Choppers spray pesticides over Queens
Disease Spreads Next few weeks Cases crop up in The Bronx and Brooklyn CDC dispatches more officers
Encephalitis Hotline 130,000 calls Overwhelmed
Banner Headlines “Killer Bug” “Let Us Spray!” Pesticide campaign involves entire city
o Case shows up in ManhattanCallers Into Hotline
Dead crows all over Connection?
Bronx Zoo Crows, flamingo, cormorant, pheasant, bald eagle:
All dead Zoo’s veterinary pathologist, Tracey McNamara
o Sends specimens to National Veterinary Services Laboratories (Iowa) Lab isolates virus Virus analyzed by CDC at Ft. Collins, CO
Door-To-Door October EIS collect blood samples from families in Queens
o 3% had antibodies to WNV Estimate
o At least 8,200 residents had the disease Most asymptomatic
November, 1999 NYC epidemic concluded 62 confirmed cases
o Survivors 1.5 years later: Needed assistance with
chores of daily livingo 7 deaths
EXACTLY WHAT IS PUBLIC HEALTH?Public Health
Credited with adding 25 years to the life expectancy of people in the United States in this century.o CDC
CDC’s Description
The active protection of our nation s health and ′safety,
The provision of credible information to enhance health decisions (educate the health care population in ways of maintaining good health), and
The development of partnerships with local minorities and organizations to promote good health. o CDC
10 Essential Public Health Services (TEST QUESTION MAYBE) Monitor health status to identify community health
problems. Diagnose and investigate health problems and
health hazards in the community. Inform, educate, and empower people about health
issues. Mobilize community partnerships to identify and
solve health problems. Develop policies and plans that support individual
and community health efforts. Enforce laws and regulations that protect health and
ensure safety. Link people to needed personal health services and
assure the provision of health care when otherwise unavailable.
Assure a competent public health and personal healthcare workforce.
Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
Research for new insights and innovative solutions to health problems.
Public Health...What Comes to Mind? (TEST QUESTION MAYBE)
Conventional ideas o Services for the Poor o Sanitation and Clean Water o Restaurant Inspections o STIs and TB Clinics
Contemporary application o Handgun Controlo Responding to Antimicrobial Resistance (MRSA) o West Nile Viruso Pandemic/Avian Fluo Childhood Obesityo Public Health Preparedness/Disasterso Terrorismo Addressing Disparities in Health Care/Health and
Human RightsLucas County Public Health
Education: CV, HIV Disaster response services and disaster
preparedness education and awareness to the community o Medical Reserve Corps
Advanced Practice Center: to serve the public health community, providing resources ranging from training tools to prepare for and respond to mass
casualty incidents to public education materials to tools to help you reach vulnerable populations.
Environmental Health: Food, Septic tanks/wells, rodent control, housing, lead poison prevention, tattooing; infant mortality review, Human trafficking
Health Services: WIC, dental, etc. Wood County: Health Services
Breastfeeding Promotion Child Fatality Review Board Dental Care Diabetes Fetal Alcohol Syndrome Flu vaccine Help Me Grow Immunizations Medical Care: Preventive/ Primary Infectious Diseases Influenza (Flu) Lead Poisoning Pharmacy Network Screenings Tobacco Travel Vaccines West Nile Virus
Wood County: Environmental Services Birth and Death Records Disaster Preparedness Flooding Safety Food Inspections Food Safety Permits and Licenses Rabies and Dog Bites Sewage Program Tattoo and Piercing Risks
Actual causes of death in the US (not on test) Half of all deaths result from nine causes.
1990 2000
Tobacco 400,000 (19%) 435,000 (18.1%) Poor Diet and 300,000 (14) 400,000 (16.6)
Physical inactivity Alcohol 100,000 (5) 85,000 (3.5)
consumption Microbial agents 90,000 (4) 75,000 (3.1) Toxic agents 60,000 (3) 55,000 (2.3) Motor Vehicle 25,000 (1) 43,000 (1.8) Firearms 35,000 (2) 29,000 (1.2) Sexual Behavior 30,000 (1) 20,000 (0.8) Illicit drug use 20,000 (<1) 17,000 (0.7) Total 1,060,000 (50) 1,159,000 (48.2)
CDC’s Ten Great Public Health Achievements in the 20th Century (PROB ON EXAM-memorize it)
Immunizations Motor-Vehicle Safety � Workplace Safety Control of Infectious Diseases Declines in Deaths from Heart Disease and Stroke Safer and Healthier Foods Healthier Mothers and Babies � Family Planning Fluoridation of Drinking Water Tobacco as a Health Hazard
Immunizations Vaccine-preventable diseases
o Smallpox 1798 o Rabies 1885 o Typhoid 1896 o Cholera 1896 o Plague 1897 o Diphtheria 1923 o Pertussis 1926 o Tetanus 1927 o Tuberculosis 1927 o Influenza 1945 o Yellow fever 1953 o Poliomyelitis 1955 o Measles 1963 o Mumps 1967o Rubella 1969o Anthrax 1970o Meningitis 1975o Pneumonia 1977 �o Adenovirus 1980 �o Hepatitis B 1981 �o H influenzae type b 1985 �o Japanese encephalitis 1992 o Hepatitis A 1995o Varicella 1995o Lyme disease 1998o Rotavirus 1998
Motor-Vehicle Safety
Workplace Safety
Control of Infectious Diseases
Declines in Deaths from Heart Disease and Stroke
Change in CV risk factors over the years
Adults aged 20-74 years with hypertensiono 1960-1962 37% �o 1988-1994 23%
Adults aged 20-74 years with high blood cholesterol o 1960-1962 32% �o 1988-1994 19%
Adults aged 18+ years who are current smokers �o 1965 42% �o 1995 25%
Persons who are overweight �o 1960-1962 24% �o 1988-1994 35% (significant increase)
Number of physicians indicating cardiovascular diseases as their primary area of practice o 1975 5,046 o 1996 14,304
Safer and Healthier Foods Nutrition
o Discovery of essential nutrients and their roles in disease prevention : “Vital Amines”
Food safetyo Hand washing, sanitation, refrigeration,
pasteurization, and pesticide applicationo Vaccines/antibiotics
Healthier Mothers and Babies Environmental interventions, improvements in
nutrition, advances in clinical medicine, improvements in access to health care, improvements in surveillance and monitoring of disease, increases in education levels, and improvements in standards of living contributed to this remarkable decline
Significant disparities by race and ethnicity persist.
Family Planning (don't need to memorize the timeline) Publicly supported family planning services prevent
an estimated 1.3 million unintended pregnancies annually
Milestones in family planning – United States, 1900-1997
1914: Margaret Sanger arrested for distributing birth control information
1916: First birth control clinic, Brooklyn, New York (closed after 10 days by the New York Vice Squad)
1925: First manufacture in the United States of diaphragms
1928: Timing of ovulation established 1937: AMA endorses birth control 1937: First state (North Carolina) includes birth
control in a public health program 1942: Planned Parenthood Federation of America
established 1960: The birth control pill approved by Food and
Drug Administration (FDA) 1960: Intrauterine device approved by FDA 1965: Supreme Court (Griswold vs. Connecticut)
declares unconstitutional state laws prohibiting contraceptive use by married couples
1970: Family Planning Services and Population Research Act creates Title X of the Public Health Service Act
1972: Medicaid funding for family planning services authorized
1973: Supreme Court (Roe vs. Wade) legalizes abortion
1990: Norplant®* approved by FDA 1992: Depo-Provera® approved by FDA1993Female
condom approved by FDA 1997: Emergency use of oral contraceptive pills
approved by FDAFluoridation of Drinking Water
Dr. Frederick S. McKay noted an unusual permanent stain or "mottled enamel" on the teeth of many of his patients.o After years of personal field investigations,
McKay concluded that an agent in the public water supply probably was responsible for mottled enamel. McKay also observed that teeth affected by this condition seemed less susceptible to dental caries
Classic example of clinical observation leading to epidemiologic investigation and community-based public health intervention.
Water fluoridation remains the most equitable and cost-effective method of delivering fluoride to all members of most communities, regardless of age, educational attainment, or income level.
Tobacco as a Health Hazard
Ten Great Public Health Achievements— U.S. 2001-2010 Vaccine-Preventable Diseases Prevention and Control of Infectious Diseases Tobacco Control Maternal and Infant Health Motor Vehicle Safety Cardiovascular Disease Prevention Occupational Safety Cancer Prevention Childhood Lead Poisoning Prevention Public Health Preparedness and Response
THE ROOTS OF AMERICAN PUBLIC HEALTH1798—John Adams
Signed into law the Act for the Relief of Sick and Disabled Seamen.
1799, Congress extended the Act to cover every officer and sailor in the U.S. Navy.
The Act led to the gradual creation of a loose network of locally controlled marine hospitals along coastal and inland waterways.
Origin of The Surgeon General 1870—Hospital administration was centralized in the
Marine Hospital Service,o Its headquarters in Washington, DCo Under the position of supervising surgeon (later
Surgeon General).1871—John Maynard Woodworth
First Surgeon General Adopted a military model for his medical staff as part
of system reform. Instituted examinations for applicants, put
physicians in uniforms, and created a cadre of mobile, career-service physicians who can be assigned to various marine hospitals.
National Quarantine Act 1878—The prevalence of major epidemic diseases
such as smallpox, yellow fever, and cholera spurred Congress to enact the National Quarantine Act to prevent the introduction of contagious and infectious diseases into the United States.
Congress later extended the Act to prevent the spread of disease among the states. The task of controlling epidemic diseases through quarantine and disinfection measures, as well as immunization programs, fell to the Marine Hospital Service.
The Commissioned Corps 1889—Legislation formalized the Commissioned
Corps as the uniformed services component of the Marine Hospital Service.
Congress organized Corps officers along military lines, with titles and pay corresponding to Army and Navy grades.
Public Health and Marine Hospital Service 1902—Name of the Marine Hospital Service
expanded to Public Health and Marine Hospital Service to reflect growing responsibilities.
The Service now carried out the medical inspection of arriving immigrants, such as those landing at Ellis Island in New York, as well as former State quarantine responsibilities.
Commissioned Corps officers played a major role in fulfilling the Service's commitment to preventing disease from entering the country.
Public Health Service 1912—Name of the Public Health and Marine
Hospital Service shortened to the Public Health Service (PHS).
Legislation enacted by Congress broadened the powers of the PHS by authorizing investigations into human diseases (such as tuberculosis, hookworm, malaria, and leprosy), sanitation, water supplies, and sewage disposal.
New Developments 1930 and 1944: Corps officers expanded to include
engineers, dentists, research scientists, nurses, and other health care specialists, as well as physicians.
Today’s Commissioned Corps Today—The Commissioned Corps continues to fulfill
its mission to protect and promote the public health of our Nation.
More than 6,500 active-duty officers Today’s mission: the Corps is working to create a
global world free of preventable disease, sickness, and suffering.
PART DEUX: CHALLENGES FOR YOU, PUBLIC HEALTH AND YOUR COMMUNITYPerspectives ofPublic Health and Medicine: AAMC
What Will Medical Practice Look Like In The Future? Shortage of public health trained professionals in the
field (Center for Studying Health System Change) Physician shortage to quadruple within decade
(Association of American Medical Colleges) The number of physicians practicing in governmental
public health should be doubled (Institute of Medicine)
THE NATURAL THREAT: NEW MADRID
Where?o The New Madrid region is located in the middle
of the vast North American tectonic plate.o In contrast to plate boundary settings like the
coasts of California or Alaska 1811 and 1812
o The 1811 and 1812 New Madrid Earthquakes: most intense intraplate earthquake series to have occurred in the contiguous USA
o Named for the Mississippi River town of New Madrid
o Felt strongly over roughly 50,000 square miles, and moderately across nearly 1 million square miles. The1906 San Francisco earthquake was
felt moderately over roughly 6,000 square miles.
Latest Researcho Research out of Virginia Tech shows a large
scale New Madrid quake (7.7 magnitude) could result in 80,000 injured, 3,500 fatalities and millions of people displaced.
o Due to the extensive damage to critical infrastructure and buildings, 2 million people would seek shelter. �
Results o Tennessee, Arkansas, and Missouri: most
severely impacted. o Illinois and Kentucky are also impacted, though
not as severely o Nearly 715,000 buildings are damaged o About 42,000 search and rescue personnel o 3,500 damaged bridges o Nearly 425,000 breaks and leaks to both local
and interstate pipelines. o ~2.6 million households without power after
the earthquake. o Nearly 86,000 injuries and fatalities result from
damage to infrastructure. o Nearly 130 hospitals are damaged and most are
located in the impacted counties near the rupture zone.
o Hampered: Search and rescue as well as evacuation.
o Roughly 15 major bridges unusable. 3 days Later
o 7.2 million people are still displaced and 2 million people seek temporary shelter.
o Direct economic losses for the eight states total nearly $300 billion
o Indirect losses may be at least twice this amount.
Oddso It is not possible, however, to make specific
predictions of when a large earthquake might strike.
o USGS estimates the chance of having an earthquake similar to one of the 1811–12
sequence in the next 50 years is about 7 to 10 percent, and the chance of having a magnitude 6 or larger earthquake in 50 years is 25 to 40 percent.
o The odds of another 8.0 event within 50 years in the New Madrid zone are between 7 and 10 percent, geologists said in 2005.
THE INFECTIOUS DISEASE THREAT: PANDEMIC A Severe (1918-like) Pandemic
o 90 million illo 45 million needing medical care o 9.9 million hospitalizationso 1.5 million needing ICUo 743,000 ventilatorso 1.9 million deaths
The 4th Weeko PODs: Manning requirements
Point of Distribution (exam Q)—where the medicine and tx are distributed This is where vaccines, etc would be
given to large #’s of ppl in an emergency
o ACS: Manning requirements o Healthcare on the brink
Your hospitals should have planned for triple the normal critical care capacity
Your hospitals should have been able to provide EMCC for 10 days without outside support
Illinoiso Potential Pandemic Flu Deaths and
Hospitalizations in IL (15-35% attack rate) Projected dead: 4,000-9,000 Projected hospitalized: 12,000-38,000 Projected outpatient: .75 million-2 million Projected cases: 2 million-4.5 million
New York Stateo 19 milliono Severe scenario (6 week outbreak)
771,000 admissions 153,000 deaths Ventilator shortfall: 12,000
Now what? Prioritization of Care Allocation of Scarce Resources Catastrophic Medicine What is the trigger or triggers that allow us to
deviate from disaster medicine to catastrophic medicine ? o From individual care to communal care?
Who decides? Looking at these issues at 3 phases...
Pre-hospital o To EDo To ACSo To Hospice
ED
o Palliativeo Admit
Intra-hospitalo Withdrawal of care
Ethical Considerations in a Pandemic Event If there’s no plan to allocate scarce resources and to
ration care...o Is that unethical? �o Subsequent actions
Arbitrary Inconsistent Uninformed Easily influenced Secretive (“Double secret probation”)
Crisis standards of care A substantial change in usual healthcare operations
and the level of care it is possible to deliver, which is made necessary by a pervasive (e.g., pandemic influenza) or catastrophic (e.g., earthquake, hurricane) disaster.
Not a choice Failure to adopt crisis standards of care – is very
likely to result in greater death, injury or illness. Disaster & Catastrophe: The Difference
Disaster: The patiento Providing scarce resources appropriately given
the severity of the condition and the likelihood of recovery
o Deliver the most basic level of care based upon established evidence-based outcomes No regard to age, race, gender, religion,
ethnicity, social worthiness, etc. o Exceptions
Children Pregnant with viable fetus
Catastrophe: The patient & the public welfareo Balance between the individual and The
Common Good A Delicate Balance
Individual liberties Protect public from harm Proportionality Privacy Duty to provide Reciprocity
o Support those who support Equity
o All with equal claim Trust Solidarity
o We’re all in it together Stewardship
o For those in governanceKey Components of an Ethical Framework (QUESTION ON TEST)
Fair
o Reflects community’s values Transparent Accountable Consistent Flexible Proportional
Guiding ethical decision-making Reasonable Transparent Inclusive Responsive Accountable
o Canada Duty to care Duty to steward resources Duty to plan Distributive justice
o One plan for all Transparency
o NYSSevere Pandemic
Catastropheo Shifting from individual care to communal careo “Medical staff...will be expected to change the
paradigm of care....a duty to the population as opposed to the individual.”
Objectiveso Care for the patiento Maintain integrity of the community
Where’s the balance?o Who provides the balance?
Decision to ration care Requires an ethical framework
o Integrate abstract principles with concrete dilemmas to arrive at an acceptable solution
o Utilitarian Scarce resources to those who would likely
benefit o Egalitarian (intrinsic)
Everyone equal Lottery system First-come-first-served
o Instrumental (extrinsic) Scare resources to those who would
advance the survival of the infrastructure EMS calls
Absenteeism: 24% � Director: Dead Medical Director: ICU on a vent Requires dispatch/transport guidelines
o Transport/No Transporto Transport guidelines
Hospital & elsewhere911: Dispatch or Not?
76 y-o Mo Achy chest pain; SOBo Multiple medical problems
42 y-o F
o Achy chest pain; SOB o PMH: hypertension
16 y-o Mo Achy chest pain; SOB o Asthmatic
Cops call 911: Dispatch or Not? MVA
o 80s Hit head; neck pain
o 42 Hit head; neck pain
o 16 Hit head; neck pain
Abdominal pain x 2 hours ino 76 yo with COPD and prostate Cao 76 yo with hypertension and heart disease o 76 yo renal dialysis patiento 76 yo ventilator-dependento 76 yo previously healthy golfer
Proposed EMS Inclusion Criteria The patient must have 1 of the following A. Requirement for invasive ventilatory support
o Refractory hypoxemia (SpO2 < 90% on non-rebreather mask or FIO2 > 0.85)
o Clinical evidence of impending respiratory failure
o Inability to protect or maintain airway B. Hypotension (systolic blood pressure < 90 mm Hg
or relative hypotension) with clinical evidence of shock (altered level of consciousness, decreased urine output or other evidence of end-organ failure) refractory to volume resuscitation
TRANSPORTEMS: ED Exclusion Criteria
The patient is excluded from admission or transfer to critical care if any of the following is present:
A. Severe trauma B.Severe burns of patient with any 2 of the
following: o Age > 60 yr o > 40% of total body surface area affected o Inhalation injury
C. Cardiac arrest o Unwitnessed cardiac arrest o Witnessed cardiac arrest, not responsive to
electrical therapy (defibrillation or pacing) o Recurrent cardiac arrest
D. Severe baseline cognitive impairment E. Advanced untreatable neuromuscular disease F. Metastatic malignant disease G. Advanced and irreversible immunocompromise H. Severe and irreversible neurologic event or
condition I. End-stage organ failure meeting the following
criteria: o Heart: NYHA class III or IV heart failure o Lungs: Severe COPD, CF, etc. o Liver: Jaundice, ascities
J. Age > 85 yr K. Elective palliative surgery CMAJ
ED Non-Admission Criteria The patient is excluded from admission or transfer to
critical care if any of the following is present: A. Severe trauma B. Severe burns of patient with any 2 of the
following: o Age>60yr o > 40% of total body surface area affected o Inhalation injury
C. Cardiac arrest o Unwitnessed cardiac arrest o Witnessed cardiac arrest, not responsive to
electricaltherapy (defibrillation or pacing) � o Recurrent cardiac arrest
D. Severe baseline cognitive impairment E. Advanced untreatable neuromuscular disease F. Metastatic malignant disease G. Advanced and irreversible immunocompromise H. Severe and irreversible neurologic event or
condition I. End-stage organ failure meeting the following
criteria:o Heart: NYHA class III or IV heart failure o Lungs
COPD with FEV1 < 25% predicted, baseline PaO2 < 55 mm Hg, or secondary
pulmonary hypertension Cystic fibrosis with postbronchodilator
FEV1 < 30% or baseline PaO2 < 55 mm Hg Pulmonary fibrosis with VC or TLC < 60%
predicted, baseline PaO2 < 55 mm Hg, or secondary pulmonary hypertension
Primary pulmonary hypertension with NYHA class III or IV heart failure, right atrial pressure > 10 mm Hg, or mean pulmonary arterial pressure > 50 mm Hg
o Liver: Child–Pugh score 7 J. Age>85yr K. Elective palliative surgery
Child-Pugh (Liver Disease) Total bilirubin Serum albumin INR Ascites Encephalopathy 1-3 points apiece Points One year survival Two year survival
o 5-6 100% 85%o 7-9 81% 57%o 10-15 45% 35%
Who meets your ED Exclusion Criteria? House Fire Victim
o 16 yo Fo 45% TBSA (total body SA) 2nd-3rd degree burns o GCS:10
GCS: Glasgow coma scale—gives conscious state of a person
o Stridoro Soot around face and moutho VS: 124-34-146/78o SaO2: 86%
Febrile geriatric patiento Nursing Homeo 101-116-28-92%-90/60o Alzheimer'so Coughing, gagging, vomiting
Young Mom with Fever and 3 kidso 32 o Smoker o Recently diagnosed with breast CA o Had seizure 2 weeks ago and is scheduled for a
Brain MRI tomorrow o 103-100-120/86-24-92%
Former Mayor: Cough, weak, black stoolso 88 yoo 101.8-120-102/54-28-94%
Child with cystic fibrosis: SOB & Fevero 15 yoo 102.4-124-26-98/56-88% o Baseline PaO2: 53 mmHg
Quadriplegic-Vent-dependent: Fever, Dyspnea, and dehydratedo 28 yoo Marineo Injured 2° IED in Afghanistan o 102.2-134-32-90/60-92%
Cardiac Arresto Mid-fortieso Found in ED bathroom o Not sure how longo VS: 0-0-0-0-0
Can we harvest ventilators from certain chronically-ill, permanently disabled patients in certain extended care facilities?
Who decides MVA Vic-Steering wheel injury
o 20so Flail chesto EMSo Spinal precautions, IVso 128-40 (shallow)-60/0-76% o Loses VS at ED ambulance bay
AIS Score Injuryo 1 Minoro 2 Moderateo 3 Seriouso 4 Severeo 5 Criticalo 6 Unsurvivable
MVA Vic-Steering wheel injuryo 20so Flail chest
o EMSo Spinal precautions, IVso 128-40 (shallow)-60/0-76%o AIS: 5 (Critical)o FAST: Blood in peritoneum (tons) o How much blood to allot?
Frequent Flyer- Weak, Dizzy & SOB!o 62o Smoker-Drinkero All around good time girl o CRF-Dialysiso Non-complianto Pulmonary edemao 102.8-156-38-80/40-90%
Overdose o 18 yoo Cocaine, heroin, ETOH, Mom’s digoxin o Suicide noteo No more than 1.5 hours agoo 96.8-40-8-76/46-86%
Should all Nursing Home patients be DNRCC?o Who decideso What is the process?
ICU-Type Patientso Withdrawal of Care
Decision-Makerso Triage Officer-Physiciano CCNo RT and/or Pharmacisto Support personnel o Others?Attorneys? Religious? Ethicist? o Shifts: 12-16 hourso 24-7o Appeal process? o QA process
o ICS: Incident Command System
SOFA: Sequential Organ Failure Assessment Score Objectively quantifies the degree of organ
dysfunction over time in order to evaluate the time course of the severity of dysfunction
The SOFA score combines a clinical assessment of 2 organ systems, cardiovascular system and central nervous system, with laboratory measurements for evaluation of 4 other organ systems: �o respiratory, hematologic, liver, renal
The greater the SOFA score for each organ, the greater the risk of death;
Six-organ dysfunction/failure score measuring multiple organ failure daily.
Each organ is graded from 0 (normal) to 4 (the most abnormal), providing a
Daily score of 0 to 24 points. Independent of the initial score, an increase in SOFA
score during the first 48 hours in the ICU predicts a mortality rate of at least 50%.
SOFA Triage •Blue: High probability of mortality; should be
discharged from critical care and should receive medical management and palliative care as appropriate;.o Initial: Exclusion criteria or SOFA > 11o 48 hours: Exclusion criteria or SOFA > 11 or
SOFA 8-11 unchangedo 120 hours: Exclusion criteria or SOFA > 11 or
SOFA < 8 unchanged Red: Highest priority for critical care
o Initial: SOFA ≤ 7 or single organ failureo 48 hours: SOFA < 11 and decreasingo 120 hours: SOFA < 11 and decreasing
progressively Yellow: Intermediate priority for critical care
o Initial: SOFA 8-11o 48 hours: SOFA < 8 unchangedo 120 hours: SOFA < 8 with minimal decrease (< 3
point decrease in 72 hours) Green: Low probability of mortality; defer admission/
discharge from critical careo Initial: no significant organ failureo 48 hours: no longer ventilator dependent o 120 hours: no longer ventilator dependent
MSOFA The score eliminates the platelet count, replaces
partial pressure of arterial oxygen (PaO2) with arterial oxygen saturation measured by a pulse oximeter (SpO2), and replaces serum bilirubin with clinical assessment of scleral icterus or jaundice .
The only laboratory value required for the MSOFA is creatinine
The MSOFA predicts mortality as well as the SOFA and is easier to implement in resource constrained
settings, but using either score as a triage tool would exclude many patients who would otherwise survive
Exclusion criteria Very high risk of death Little likelihood of long-term survival Low likelihood of benefit from critical care resources Based on
o SOFA + Severity of Chronic IllnessOne Exclusion Criteria model using SOFA
Must have an 80% risk of deatho SOFA score ≥ 15 any timeo Mean SOFA score ≥ 5 for 5 days or more + a flat
or rising trend o 6 or more organ failures t any time
Hospital IC Down to one ventilator
Withdrawal of life support 60-y-o patient on ventilator
o SOFA scores over 3 days: worse (20) 20-y-o in ER needs vent Are criteria met to remove vent from 1 and give it to
the other? 20-y-o patient on ventilator
o SOFA scores over 3 days: worse (20) 70-y-o in ER needs vent 60-y-o Congresswoman on ventilator
o SOFA scores over 3 days: worse (20) 20-y-o prisoner in ER needs vent 30-y-o convicted rapist on ventilator
o SOFA scores over 3 days: worse (20) 60-y-o state senator in ER needs vent Are criteria met to remove vent from 1 and give it to
the other? Who decides Who actually does it What are the legal ramifications?
What are the steps to recovery? Achieving “The New Normal” Educational venues: closed Public gatherings: suspended Religious services: curtailed Mass graves Alternative care sites: operational Possible retribution Mental health
A MULTI-NODAL UNI-JURISDICTIONAL ATTACK Historical Perspective
o Madrid, 2004 o London, 2005 o Mumbai, 2008
Madrid Madrid train bombings (11-M)
o Nearly simultaneous, coordinated bombings against the commuter train system of city of Madrid, Spain
o On the morning of 11 March 2004 – three days before Spain's general elections.
o The explosions killed 191 and wounded 1,800.
London: 7 July 2005 Thursday morning 4 terrorists detonated four bombs 3 in quick succession aboard London Underground
trains across the city A fourth on a double-decker bus Fifty-two civilians plus the 4 bombers were killed in
the attacks Over 700 more were injured.
Mumbai, 11/26/2008
Toledo, May 2 Breaking News 9:11 PM: A series of ambulance
bombs and 10-20 assailants armed with assault rifles and grenades have just attacked all the ERs in the Toledo-area.
Dead are in the hundreds. Wounded may be near 1000. Alleged assailants have been neutralized. ER evacuations, search-and-rescue under way
What is local Public Health doing? ICS Overview
o Incident Command Structure or ICS is a systematic tool used for the command, control, and coordination of emergency response
o ICS is Flexible and Scalable – ICS is organized in such a way as to expand and contract as needed by the incident scope, resources and hazards. It can be used for any size emergency.
ICS Characteristicso Common Terminology o Integrated Communicationso Modular Organization o Management by Objectives o Incident Action Planning o Manageable Span of Control o Incident Facilities and Locations o Comprehensive Resource Management o Establishment and transfer of Commando Chain of Command and Unity of Commando Unified Commando Dispatch/Deployment o Accountabilityo Information and Intelligence Management
Incident Command System (ICS)